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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS p �/��' ✓ w / a (_-q— Z-� /J�91 /� APN c)(L S- W / CROSS STREET Lkww.= � a#(-- JI(L PARCELSIZE /{/�'n OWNER NAME ::2F r6/ ! /Y'r PHONE OWNER ADDRESS S CITY/STATE/ZIP 'fat FOUNDATION ft PROPERTY LINE CONTRACTOR CJIY��GI VCIILv% PHONE FILTER BED WIDTH ft LENGTH CONTRACTOR 316 O �50 h 191. CITY/STATE/ZIP /q �/ GpX�L�. C 4 / `5 T� �ADDRESS // Com{`/ LICENSE ❑xY -42 ❑❑C-36 OTHER NUMBER 4`S5e' s EXPIRATION DATE FOUNDATION ft PROPERTY LINE ft WATER TABLE DEPTH: O ' O ft GEOGRAPHICAL INFORMATION: Coordinates X Y ❑ PERC TEST # BUILDING PERMIT # LAND USE APPLICATION # TYPE OF WORK: ❑ NEW INSTALLATION REPAIR/ADDITION L ENGINEER DESIGNED /ALTERNATIVE ❑ REPLACEMENT ❑ OUT -OF -SERVICE SEPTIC SYSTEM ❑ DESTRUCTION INSTALLATION WILL SERVE: RESIDENCE 11 COMMERCIAL El OTHER /� '7 NUMBER OF LIVING UNITS: -J—NUMBER OF BEDROOMS: i NUMBER OF EMPLOYEES: 1 ❑ SEPTIC TANK TYPE/MFG C S� ^ % 0 CAPACITY gal # OF COMPARTMENTS ❑ GREASE TRAP TYPE/MFG CAPACITY gal # OF COMPARTMENTS DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR (ENCLOSED SYSTEM) Application Accepted By —,4 4A VA Date Final Inspection By /T Date 10 Character of Soil to Depth o 3 Ft: COMMENTS Area Employee ID#� ❑ SPECIAL PERMIT -Approved by Character: PE SC Received `/_0 / Permit/ Date LEACH LINES ❑ LEACHING CHAMBERS # OF LINES / LENGTH OF LINES ft INFO 8 Oo Sd SO ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH ft DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft SEEPAGE PITS NUMBER _7 WIDTH 10 ft DEPTH r�J ft ,[�' DISTANCE TO NEAREST WELL �SO r/ ft FOUNDATION 8O f ft PROPERTY LINE SO ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. MINIMUM 98 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL 209 953-7697 SIGNED i //- O TITLE �r'1f7�ilf�� DATE Application Accepted By —,4 4A VA Date Final Inspection By /T Date 10 Character of Soil to Depth o 3 Ft: COMMENTS Area Employee ID#� ❑ SPECIAL PERMIT -Approved by Character: PE SC Received eck#P Amount Permit/ Date Invoice #ROMVED Code INFO 8 sh Remitt d Service Request # �u _ .A 50, u0 1' -IS OCT 16 2018 T N s 42-01 ONSITE WASTEWATEf14P`I� 4/24/12 EI NV1R� HEALTH DEPARTMENT